A Taic investigation recommended KiwiRail's Port Otago operation improve its safety culture. Photo / KiwiRail
A Taic investigation recommended KiwiRail's Port Otago operation improve its safety culture. Photo / KiwiRail
Two KiwiRail workers narrowly avoided being crushed after nine wagons weighing 472 tonnes were wrongly secured.
A report released today by the Transport Accident Investigation Commission (Taic) found safety culture and training at KiwiRail’s Port Otago operation contributed to the hazardous incident.
About 1.25am on January 23 last year,a remote-control operator and a rail operator were moving 25 wagons for a freight transfer at the Port Otago rail storage facility at Port Chalmers.
After parking nine wagons in the marshalling yard on a slight gradient, they moved the locomotive to collect the remaining wagons.
However, as they coupled the locomotive to the first of the second set of wagons, one of the workers spotted a moving shadow and realised the nine wagons were rolling back down the gradient towards them.
“This event was low-speed, but not low-risk,” she said.
“Hazards are greatest when people are close to or between vehicles, making them vulnerable to being taken by surprise, as occurred here, where the wagons were only detected at the last minute due to the shadow they cast.”
Taic investigators said they found signs that “rule violations and unsafe practice” had become “normalised” at the site and that previous incidents had not been reported reliably.
The commission found the wagons had not been correctly secured, and the workers had not clearly confirmed the securing task was complete before moving on to the next job.
Cook said switching tasks was a common moment for safety lapses, as attention could shift to the new job before the previous one was fully finished.
“In higher-risk work, any change in task should trigger a deliberate safety reset, so crews reassess the risk and apply the right controls before moving on.”
Staff were also found to lack sufficient understanding of the “air-brake system, equalisation timing, or the risk of trapping air in the system”, despite training in these areas.
“Procedure compliance is more robust when workers understand the ‘why’ as well as the ‘do’,” Cook said.
She added that local operating culture could make unsafe actions seem routine, so non-compliance started to look like “the way we do things around here”.
Taic recommended that KiwiRail improve safety culture at Port Otago, strengthen shunt staff training, and review remote-control packs so emergency stops can alert train control even when the locomotive is stationary.
